Repeated and adaptive multidisciplinary assessment of a patient with acute pulmonary embolism and recurrent cardiac arrests

2020 ◽  
Vol 13 (9) ◽  
pp. e234647
Author(s):  
Karin Fryk ◽  
Christian Rylander ◽  
Kristina Svennerholm
Keyword(s):  
Pulmonary Embolism ◽  
Cardiac Arrest ◽  
High Risk ◽  
Intravenous Thrombolysis ◽  
Initial Therapy ◽  
Complex Case ◽  
Therapeutic Decisions ◽  
Threatening Condition ◽  
Life Threatening ◽  
Va Ecmo

High-risk pulmonary embolism (PE) is a life-threatening condition that must be recognised and treated rapidly. The importance of correct risk stratification to guide therapeutic decisions has prompted the introduction of multidisciplinary PE response teams (PERTs). The recommended first-line treatment for high-risk PE is intravenous thrombolysis. Alternatives to consider if thrombolysis has insufficient effect or may cause significant haemorrhagic complications include catheter-directed intervention (CDI) and surgical thrombectomy. For patients in deep shock or cardiac arrest, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can be instituted for cardiopulmonary rescue and support during CDI, thrombectomy or pharmacological treatment. We present a complex case of high-risk PE that illustrates the importance of an early PERT conference and repeated decision-making when the initial therapy fails. After a trial of thrombolysis with insufficient effect, VA-ECMO was used to reverse circulatory and respiratory collapse in a patient with PE and recurrent episodes of cardiac arrest.

scholarly journals Reduced-dose intravenous thrombolysis for acute intermediate high-risk pulmonary embolism: Rationale and design of the PEITHO-3 trial

2021 ◽  
Author(s):  
Olivier Sanchez ◽  
Anais Charles-Nelson ◽  
Walter Ageno ◽  
Stefano Barco ◽  
Harald Binder ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Functional Limitation ◽  
Intravenous Thrombolysis ◽  
Primary Efficacy ◽  
Double Blind ◽  
Primary Efficacy Outcome ◽  
Reduced Dose ◽  
Efficacy Outcome ◽  
Life Threatening

Intermediate high-risk pulmonary embolism (PE) is characterised by right ventricular (RV) dysfunction and elevated circulating cardiac troponin levels despite apparent haemodynamic stability at presentation. In these patients, full-dose systemic thrombolysis reduced the risk of haemodynamic decompensation or death but increased the risk of life-threatening bleeding. Reduced-dose thrombolysis may be capable of improving safety while maintaining reperfusion efficacy. The Pulmonary Embolism International Trial (PEITHO)-3 study (EudraCT 2018-000816-96) is a randomised, placebo-controlled, double-blind, multicentre, multinational trial with long-term follow-up. We will compare the efficacy and safety of a reduced-dose alteplase regimen with standard heparin anticoagulation. Patients with intermediate high-risk PE will also fulfil at least one clinical criterion of severity: systolic blood pressure ≤ 110 mmHg, respiratory rate >20 breaths/min, or history of heart failure. The primary efficacy outcome is the composite of all-cause death, haemodynamic decompensation or PE recurrence within 30 days of randomisation. Key secondary outcomes, to be included in hierarchical analysis, are fatal or GUSTO severe or life-threatening bleeding; net clinical benefit (primary efficacy outcome plus severe or life-threatening bleeding); and all-cause death, all within 30 days. All outcomes will be adjudicated by an independent committee. Further outcomes include PE-related death, haemodynamic decompensation, or stroke within 30 days; dyspnoea, functional limitation or RV dysfunction at 6 months and 2 years; and utilisation of healthcare resources within 30 days and 2 years. The study is planned to enrol 650 patients. The results are expected to have a major impact on risk-adjusted treatment of acute PE and inform guideline recommendations.

Use of extracorporeal membrane oxygenation in acute pulmonary embolism: a pooled analysis

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
L Baldetti ◽  
A Beneduce ◽  
L Cianfanelli ◽  
G Falasconi ◽  
L Pannone ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Cardiac Arrest ◽  
Survival Rate ◽  
High Risk ◽  
Observational Studies ◽  
Acute Pulmonary Embolism ◽  
Ecmo Support ◽  
Hospital Survival ◽  
Va Ecmo ◽  
Obstructive Shock

Abstract Background High-risk acute pulmonary embolism (PE) is burdened by a mortality as high as 65%. VenoArterial ExtraCorporeal Membrane Oxygenation (VA-ECMO) may offer a cardiopulmonary support and a precious time window to ensure pulmonary reperfusion therapies. No definite consensus exists on the use of VA-ECMO in high-risk PE patients as only sparse observational studies are available yielding conflicting outcomes. Purpose To provide insights on the use of ECMO in acute high-risk PE pooling together all available published experiences to date. Methods Two authors (LB, AB) searched PubMed, Embase, BioMedCentral and Google Scholar, from inception to 18/09/2019. All published clinical studies investigating ECMO support in patients with high-risk acute PE were evaluated for inclusion. Results Literature search identified 384 observational studies: a total of 66 were included for 584 acute high-risk PE patients receiving ECMO support. Mean age was 46.8±16.8 years (44% female). Most patients presented with cardiac arrest (56%) or obstructive shock (42%). Diagnosis of PE was confirmed by computed tomography (CT) in 72%, performed before ECMO cannulation in 65%. Echocardiography was obtained in 89%. Right ventricle dilatation or dysfunction was found in 90% and 87%. ECMO was primarily employed as upfront treatment (63%), in the VA-ECMO configuration (94%). ECMO was equally employed in conjunction with interventional/surgical pulmonary reperfusion treatments (38%), with thrombolysis (35%) and without adjunctive procedures (40%). Mean ECMO support duration was 100.3±12.9 hours. Notably, 92% received thrombolysis before ECMO cannulation. ECMO bailout implant was mostly adopted in patients receiving thrombolysis (81% vs 19%; p=0.010), as a rescue therapy. Most common reperfusion procedures were surgical embolectomy (28%), catheter-directed thrombolysis (12%) and transcatheter embolectomy (12%). The majority of these procedures (81%) took place after ECMO cannulation. Mean total hospital stay was 17.8±11.6 days. Hospital survival rate was 54% and did not differ in upfront vs bailout ECMO (p=0.184) and between thrombolysis, interventional procedure and ECMO alone recipients (p=0.423). Neurologic death and non-fatal neurologic injury occurred both in 10%. Most patients (70%) were successfully weaned off ECMO, while 30% died on support and 7% died after ECMO removal. Acute kidney injury was the most common complication (47%). Major bleeding occurred in 19% and was fatal for 5%. Patients undergoing thrombolysis had a tendency towards higher rates of major bleeding (48% vs 23%; p=0.05). At a mean follow-up of 365.0 (IQR 202.5–365.9) days, overall survival rate was 85% in those surviving hospitalization. Conclusions In this pooled population consisting mostly of cardiac arrest/obstructive shock PE patients, ECMO strategy was associated with acceptable in-hospital survival and was frequently used in conjunction with other reperfusion treatments. Central Illustration Funding Acknowledgement Type of funding source: None

scholarly journals Acute pulmonary embolism in COVID-19 patient: a case report of free-floating right heart thrombus successfully treated with fibrinolysis

2020 ◽  
Author(s):  
Fernando Scudiero ◽  
Antonino Pitì ◽  
Roberto Keim ◽  
Guido Parodi
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Retrospective Studies ◽  
Right Heart ◽  
Clinical Issue ◽  
Systemic Thrombolysis ◽  
Case Summary ◽  
High Prevalence ◽  
Life Threatening ◽  
Complex Scenario

Abstract Background Despite the fast-growing understanding of the coronavirus disease 2019 (COVID-19), patient management remains largely empirical or based on retrospective studies. In this complex scenario, an important clinical issue appears to be represented by the high prevalence of thromboembolic events, but the data regarding high-risk pulmonary embolism (PE) is still not available. Case summary A patient with COVID-19 developed sudden shortness of breath and hypoxia. Early echocardiographic diagnosis of high-risk PE related to right heart thrombus was performed. Systemic thrombolysis was administered with excellent clinical and haemodynamic response. Discussion Pulmonary thromboembolism is a common occurrence in severe COVID-19 infection. In our experience, systemic thrombolysis proved to be effective and for this reason may be considered for life-threatening PE in COVID-19 patients.

Effectiveness of a Dispatcher-Assisted Cardiopulmonary Resuscitation Program Developed by the Thailand National Institute of Emergency Medicine (NIEMS)

2021 ◽  
pp. 1-6
Author(s):  
Chuenruthai Angkoontassaneeyarat ◽  
Chaiyaporn Yuksen ◽  
Chetsadakon Jenpanitpong ◽  
Pemika Rukthai ◽  
Marisa Seanpan ◽  
...  
Keyword(s):  
Health Care ◽  
Emergency Medicine ◽  
Cardiac Arrest ◽  
Cardiopulmonary Resuscitation ◽  
Health Care Providers ◽  
Care Providers ◽  
Chest Compressions ◽  
Threatening Condition ◽  
Life Threatening

Abstract Background: Out-of-hospital cardiac arrest (OHCA) is a life-threatening condition with an overall survival rate that generally does not exceed 10%. Several factors play essential roles in increasing survival among patients experiencing cardiac arrest outside the hospital. Previous studies have reported that implementing a dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) program increases bystander CPR, quality of chest compressions, and patient survival. This study aimed to assess the effectiveness of a DA-CPR program developed by the Thailand National Institute for Emergency Medicine (NIEMS). Methods: This was an experimental study using a manikin model. The participants comprised both health care providers and non-health care providers aged 18 to 60 years. They were randomly assigned to either the DA-CPR group or the uninstructed CPR (U-CPR) group and performed chest compressions on a manikin model for two minutes. The sequentially numbered, opaque, sealed envelope method was used for randomization in blocks of four with a ratio of 1:1. Results: There were 100 participants in this study (49 in the DA-CPR group and 51 in the U-CPR group). Time to initiate chest compressions was statistically significantly longer in the DA-CPR group than in the U-CPR group (85.82 [SD = 32.54] seconds versus 23.94 [SD = 16.70] seconds; P <.001). However, the CPR instruction did not translate into better performance or quality of chest compressions for the overall sample or for health care or non-health care providers. Conclusion: Those in the CPR-trained group applied chest compressions (initiated CPR) more quickly than those who initiated CPR based upon dispatch-based CPR instructions.

scholarly journals T-wave inversion in the precordial leads: сardiac and non-cardiac causes

Kardiologiia ◽  
2020 ◽  
Vol 60 (5) ◽  
pp. 136-145
Author(s):  
I. R. Tsoy ◽  
I. P. Kolos
Keyword(s):  
Pulmonary Embolism ◽  
Differential Diagnosis ◽  
Anterior Wall ◽  
Left Ventricular ◽  
Arrhythmogenic Cardiomyopathy ◽  
Cardiac Memory ◽  
T Wave ◽  
Wave Inversion ◽  
Threatening Condition ◽  
Life Threatening

The T-wave inversion (TWI) is a common electrocardiographic finding. Causes for TWI are numerous and sometimes TWI may appear in life-threatening conditions. The aim of this review was to provide an up-to-date analysis of TWI, including i) definition and prevalence; ii) causes, and iii) differential diagnosis in benign TWI, reversible myocardial ischemia of the left ventricular anterior wall; takotsubo cardiomyopathy; subarachnoid hemorrhage; pulmonary embolism; right ventricular arrhythmogenic cardiomyopathy; and “cardiac memory”. The review presents practical electrophysiological criteria, which allow suspecting in time a life-threatening condition to choose an up-to-date treatment.

Secondary prevention of sudden cardiac death in ischaemic cardiomyopathy

ESC CardioMed ◽  
2018 ◽  
pp. 2337-2341
Author(s):  
Jens Cosedis Nielsen ◽  
Jens Kristensen
Keyword(s):  
Heart Failure ◽  
Cardiac Arrest ◽  
Heart Disease ◽  
High Risk ◽  
Sudden Cardiac Death ◽  
Secondary Prevention ◽  
Cardiac Death ◽  
Cardioverter Defibrillator ◽  
Ischaemic Cardiomyopathy ◽  
Life Threatening

The most common reason for sudden cardiac death is ischaemic heart disease. Patients who survive cardiac arrest are at particularly high risk of recurrent ventricular arrhythmia and sudden cardiac death, and are candidates for secondary prevention defined as ‘therapies to reduce the risk of sudden cardiac death in patients who have already experienced an aborted cardiac arrest or life-threatening arrhythmias’. The mainstay therapy for secondary prevention of sudden cardiac death is implantation of an implantable cardioverter defibrillator. Furthermore, revascularization and optimal medical therapy for heart failure and concurrent cardiovascular diseases should be ensured.

scholarly journals Prevention and Treatment of Tumor Lysis Syndrome in the Era of Onco-Nephrology Progress

2020 ◽  
Vol 45 (5) ◽  
pp. 645-660
Author(s):  
Joanna Matuszkiewicz-Rowinska ◽  
Jolanta Malyszko
Keyword(s):  
High Risk ◽  
Treatment Plan ◽  
Diuretic Therapy ◽  
Tumor Lysis Syndrome ◽  
Phosphate Binders ◽  
Tumor Lysis ◽  
Threatening Condition ◽  
Clinical Consequences ◽  
Life Threatening ◽  
Knowledge Of Cancer

Background: Tumor lysis syndrome (TLS) is an oncologic emergency due to a rapid break down of malignant cells usually induced by cytotoxic therapy, with hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia, and serious clinical consequences such as acute renal injury, cardiac arrhythmia, hypotension, and death. Rapidly expanding knowledge of cancer immune evasion mechanisms and host-tumor interactions has significantly changed our therapeutic strategies in hemato-oncology what resulted in the expanding spectrum of neoplasms with a risk of TLS. Summary: Since clinical TLS is a life-threatening condition, identifying patients with risk factors for TLS development and implementation of adequate preventive measures remains the most critical component of its medical management. In general, these consist of vigilant laboratory and clinical monitoring, vigorous IV hydration, urate-lowering therapy, avoidance of exogenous potassium, use of phosphate binders, and – in high-risk cases – considering cytoreduction before the start of the aggressive agent or a gradual escalation of its dose. Key Messages: In patients with a high risk of TLS, cytotoxic chemotherapy should be given in the facility with ready access to dialysis and a treatment plan discussed with the nephrology team. In the case of hyperkalemia, severe hyperphosphatemia or acidosis, and fluid overload unresponsive to diuretic therapy, the early renal replacement therapy (RRT) should be considered. One must remember that in TLS, the threshold for RRT initiation may be lower than in other clinical situations since the process of cell breakdown is ongoing, and rapid increases in serum electrolytes cannot be predicted.

6081Efficacy and limitations of quinidine therapy in patients with Brugada Syndrome

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
A Mazzanti ◽  
E Tenuta ◽  
M Marino ◽  
E Pagan ◽  
M Morini ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Side Effects ◽  
High Risk ◽  
Brugada Syndrome ◽  
Low Dose ◽  
Clinical Course ◽  
High Risk Group ◽  
High Dose ◽  
Life Threatening ◽  
Patients Experience

Abstract Background Quinidine at high-dose is used in patients with Brugada Syndrome (BrS), but its efficacy to prevent life-threatening arrhythmic events (LAE) in BrS is unproven and its use is limited by side effects. Objective We assessed whether low-dose quinidine in BrS patients reduces: 1) the occurrence of a first LAE; 2) the arrhythmic burden in the high-risk group of cardiac arrest survivors. Methods We first compared the clinical course of 53 BrS patients treated with quinidine to that of 441 untreated controls, matched by sex, age, and symptoms. Furthermore, we calculated the annual incidence of LAEs off- and on-quinidine in 123 BrS patients who had survived a cardiac arrest. Results First, we compared the clinical course of 53 BrS patients treated with quinidine (i.e. “cases”: 89% males, median age 40 years) to that of 441 untreated, clinically-matched BrS patients (i.e. “controls”: 91% males, median age 41 years) present in our database of patients with inherited arrhythmias. Cases received quinidine (median dose of 450 mg per day) for 5.0±3.7 years. Quinidine was interrupted in only 3/53 cases (6%) for side effects and it conferred a nonsignificant reduction of the risk of a first LAE in cases versus controls (HR 0.74, 95% CI 0.22–2.48, P=0.62). Secondly, we calculated the annual recurrence of LAE off- and on-quinidine in 123 BrS cardiac arrest survivors, 27 of whom were treated with quinidine for 7.0±3.5 years. The annual rate of recurrent LAEs decreased significantly from 14.7% while off-quinidine to 3.9% while on-quinidine (P=0.03). Notably, recurrent life-threatening arrhythmic events were recorded in 4/27 (15%) symptomatic patients while on-quinidine. Conclusion We demonstrated for the first time in the long-term that low-dose quinidine reduces the recurrence of life-threatening arrhythmias in symptomatic BrS patients, with few side effects. Remarkably, about one-fifth of symptomatic patients experience life-threatening arrhythmias while on-treatment, suggesting that quinidine cannot replace implantable defibrillators in high-risk subjects.

P5021Hypoperfusion markers identify patients with acute pulmonary embolism at highest risk for an adverse outcome

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M Ebner ◽  
C Sentler ◽  
V P Harjola ◽  
H Bueno ◽  
K Keller ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Cardiac Arrest ◽  
High Risk ◽  
Predictive Value ◽  
Odds Ratio ◽  
Adverse Outcome ◽  
A Priori ◽  
Positive Likelihood Ratio ◽  
Adverse Outcomes ◽  
Prognostic Information

Abstract Background/Introduction According to the European Society of Cardiology (ESC) 2014 guideline, systemic hypotension (HT) is the critical variable defining high-risk in patients with pulmonary embolism (PE). However, signs of organ hypoperfusion might more adequately identify PE patients with cardiogenic shock due to right ventricular (RV) failure. Purpose We investigated whether hypoperfusion markers provide superior prognostic information for identifying PE patients at highest risk of early adverse outcomes. Methods Consecutive PE patients enrolled in a prospective single-centre registry between 09/2008 and 03/2018 were included. We analysed the predictive value of symptoms and findings suggesting hypoperfusion for in-hospital adverse outcome (catecholamine treatment, resuscitation or PE-related death) and in-hospital all-cause mortality. Results We analysed 814 patients, including 83 (10.2%) ESC 2014 high-risk patients. Patients presenting with cardiac arrest (CA, 4.5%) were a priori defined as high risk. Markers suggesting hypoperfusion of the brain (altered metal status, odds ratio [OR] 8.2 [95% CI, 4.2–16.0]), lung (respiratory insufficiency, 25.0 [9.4–66.7]) and tissue (venous lactate ≥2.2 mmol/l, 6.4 [3.2–12.9]) as well as HT (13.5 [6.7–27.2]) predicted an adverse outcome. The risk for an adverse outcome increased with the number of positive markers (AUC 0.86 [0.80–0.93]). Patients with ≥3 positive hypoperfusion markers had an OR of 42.9 (11.0–167.3) and patients defined as high-risk by the ESC 2014 an OR of 17.2 (8.8–33.3) with regard to an adverse outcome (Figure 1; Table 1). A new definition of high-risk (CA or ≥3 hypoperfusion markers) was associated with an OR of 73.2 (31.3–171.1) for an in-hospital adverse outcome and 26.2 (12.1–56.7) for in-hospital mortality. Table 1. Prognostic performance of hypoperfusion markers Adverse outcome (if negative) Adverse outcome (if positive) Sensitivity Specificity LR+ OR (95% CI) ≥1 hypoperfusion marker 1.1% 21.0% 91.9% 68.2% 2.9 24.4 (7.3–80.8) ≥2 hypoperfusion markers 4.7% 50.0% 48.6% 95.5% 10.9 20.3 (9.1–45.1) ≥3 hypoperfusion markers 6.5% 75.0% 24.3% 99.3% 32.7 42.9 (11.0–167.3) ESC 2014 high-risk 5.7% 51.1% 35.0% 96.9% 11.4 17.2 (8.8–33.3) Cardiac arrest 8.4% 86.5% 33.0% 99.3% 47.3 70.1 (26.4–186.1) Abbreviations: LR+, positive likelihood ratio; OR, odds ratio; CI, confidence interval. Figure 1. Frequency of adverse outcome Conclusions Markers of organ hypoperfusion have high predictive value for early adverse outcomes in acute PE. Risk increases with the number of positive markers and is critically elevated in patients presenting with CA or ≥3 markers. Acknowledgement/Funding This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503).

Peripheral VA-ECMO with direct biventricular decompression for refractory cardiogenic shock

Perfusion ◽  
2018 ◽  
Vol 33 (6) ◽  
pp. 493-495 ◽  
Author(s):  
Prashant Rao ◽  
Jarrod Mosier ◽  
Joshua Malo ◽  
Vicky Dotson ◽  
Christopher Mogan ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Extracorporeal Membrane Oxygenation ◽  
Cardiogenic Shock ◽  
Mortality Rates ◽  
Left Ventricular ◽  
Off Pump ◽  
Novel Technique ◽  
Refractory Cardiogenic Shock ◽  
Life Threatening ◽  
Va Ecmo

Cardiogenic shock and cardiac arrest are life-threatening emergencies that result in high mortality rates. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) via peripheral cannulation is an option for patients who do not respond to conventional therapies. Left ventricular (LV) distention is a major limitation with peripheral VA-ECMO and is thought to contribute to poor recovery and the inability to wean off VA-ECMO. We report on a novel technique that combines peripheral VA-ECMO with off-pump insertion of a trans-apical LV venting cannula and a right ventricular decompression cannula.

Sign in / Sign up

Export Citation Format

Share Document